Insurance Liability Questions

INSURANCE LIABILITY QUESTIONS

Applicant / Insured Information

Policy Details

Coverage Selection

Indicate all liability coverages requested or currently in force by checking the applicable boxes:

Exclusions & Special Conditions

Are there any endorsements, exclusions, or prior agreements that materially restrict coverage under current or requested policies? Yes No

Operations & Exposures

Number of locations: Primary operations / business description:

Do you use subcontractors or independent contractors? Yes No

Are products manufactured, distributed or sold by you? Yes No

Auto & Other Liability Exposures

Does the insured operate aircraft, watercraft, cranes, hoists or elevators? Yes No

Contractual Obligations & Additional Insured

Do you enter into written contracts with indemnity, hold harmless, or additional insured obligations? Yes No

Are certificates of insurance required from vendors, subcontractors, or lessees? Yes No

Claims & Loss History (Last 5 Years)

Provide details for each claim, loss or suit in the past five years. If none, write "None".

Regulatory, Criminal, and Compliance Matters

Have there been any regulatory violations, OSHA citations, criminal convictions, or findings of fraud involving the named insured or principals in the last five years? Yes No

Safety, Security & Risk Control

Does the insured maintain written safety policies, employee training and loss control procedures? Yes No

Beneficiary / Additional Interest

List any additional interest, loss payee, mortgagee or beneficiary to be shown on policy declarations:

Declaration and Certification

The undersigned declares that the statements and particulars contained in this questionnaire are true, complete and correctly recorded to the best of the undersigned's knowledge and belief. The undersigned understands that omission or misrepresentation of material facts may void the policy or result in denial of coverage in the event of a claim. The undersigned authorizes the release of loss history and underwriting information to the insurer and its representatives for the purpose of underwriting and claims handling.

The undersigned further acknowledges that coverage is subject to the terms, conditions, limitations and exclusions of the policy issued and that no coverage is bound until an insurer or its authorized representative confirms binding in writing. The undersigned certifies that they are authorized to provide the information and to execute this questionnaire on behalf of the named insured.

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